Retained Placenta

Retain placenta is an obstetrical complication associated with significant maternal morbidity and
mortality. It is the condition in which all or part of the placenta or membranes are left behind in
the uterus (womb) during the third stage of labour. The third stage is when the placenta and
membranes are delivered. The mother will be treated for a retained placenta if the third stage
takes longer than usual or if there are signs that any of the placenta or membrane is still attached
to the uterus.

The natural third stage, which involves the mother actively delivering the placenta by pushing it
out, normally it takes about 10 to 20 minutes but sometimes it can take up to an hour (Nccwch,
2007. p.178). The third stage can be speeded up with an injection Ergometrine (iv) in the mother
thigh, given just after the baby is being born. This is known as a managed third stage and usually
takes about 5 to 10 minutes (Magann et al 2005). Managing the third stage reduces the risk of
mother experiencing heavy bleeding.

The Cause
There are three main causes of retained placenta. The first one is uterine atony – this means that
the uterus stops contracting or doesn’t contract enough for the placenta to separate from the wall
of the uterus. The second one is trapped placenta – the placenta comes away from the uterus
successfully but becomes trapped behind a closed cervix. The third one is placenta accrete – this
means that an area of the placenta remains attached because it is deeply embedded into the uterus
wall. Some other minor courses are also stated below.

A trapped placenta can happen during the management of third stage if the cord snaps during the
“controlled cord traction”. A midwife or a health worker may give an injection to the mother and
then wait for signs that the placenta has separated. These signs of placenta separated are; 1)
Uterus rises in maternal abdomen (rising fundus), 2) Uterine shape changes from discoid to
globular, 3) Umbilical cord lengthens, and 4) Vaginal fresh blood loss. Controlled cord traction
is done when left hand is applying super pubic pressure to keep the uterus steady while right
hand gently pulling on the cord to deliver the placenta.

If the placenta has separated from the wall of uterus and is ready to come out, it will slide easily
through the vagina. If it has not completely separated from the wall of uterus or if the cord is
very thin or if the midwife pulls too hard, the cord may snap and leaving the placenta inside the
uterus. If this happens then the mother can help to deliver the placenta by pushing with a
contraction when the midwife tells her to, but occasionally the cervix will have closed too much
to let the placenta out.

Retained placenta may be due to a small piece of placenta, connected to the main part of the
placenta by a blood vessel, being left behind in the uterus. This is sometimes called a
succenturiate lobe. The midwife will examine the placenta and membranes carefully after
delivery to ensure that they are complete. If she notices a vessel leading to nowhere then this
should alert her to the possibility of part of the placenta being retained.
Sometimes a full bladder will prevent the placenta from being delivered, so the midwife may
insert a catheter to drain the bladder out. (Lindsay 2004: 995).

Risk Factors
There are some risk factors of mothers being having retained placenta. If a mother has had a
history of retained placenta, than she is most likely to have another one. Also mothers, who have
previous injury to their uterus or scarring of the uterus due to previous surgery like C/Section or
infection, are at risk of having retained placenta during the third stage of labour. Pre-term
delivery mothers and mothers on induced labour are also at the risk of having retained placenta.
That’s because the placenta was designed to stay put for 40 weeks in the uterus but this was not
40 weeks. The other risk is the conditions where the uterus has been overstretched like;
multiparity or grandmultiparity, multiple pregnancy, polyhydramnios, prolonged labour, and
diabetic mothers. And also primigravidas are at risk.

Management/Treatment
The management and treatment of retained placenta are described below.

If the third stage is taking a while, the mother should advise to try breastfeeding her baby or
rubbing her nipples, as this can cause the uterus to contract and may help expel the placenta. If
the mother is sitting or lying down, advise the mother to try changing to a more upright position
so that the gravity can help to delivery the placenta. (Harris 2004. p. 512).

If the third stage managed, the mother will be given an injection of an oxytoxic drug (IMI) on the
mother’s thigh to make the uterus contract and the midwife will use controlled cord traction to
gently pull the placenta out.

If the placenta still can’t be moved, then it may need to be removed manually. Before the
placenta is removed manually, a catheter has to be inserted to empty the bladder, and then given
iv Pethidine and Diazepam or Ketamine or paracervical block to prevent any infection. Have
N/saline drip running under the manual removal. Then have x-match blood to resuscitate with as
necessary. Commence Chloramphenicol iv to perform manual removal and iv Ergometrine
0.5mg after removal to maintain uterine contraction with massage and 20 units of oxytocin in iv
infusion.

If the manual removal is difficult and the placenta has been retained for more than 72 hours, it
may cause circulatory collapse or septicaemia. Therefore, resuscitate her as above and keep the
uterus contracted with oxytocin drip. Then transfuse with packed cells if available until Hb at
least 9g%. After that, give Chloramphenicol 1g qid and Metronidazole 500g tds or (Tinidazole
1g bd for 3 days). Later if the patient is recovered; advise her that hospital delivery is essential
next time as retained placenta is likely to occur. And also carry out tubal ligation if consent can
be obtain as further pregnancy may be very dangerous. (Mola et al. 2005, p. 125-126)

Complications
There are some complications of retained placenta which are explained below.
Normally after the delivery of the placenta, the uterus contracts down to close off all the blood
vessels inside the uterus. If the placenta is only partially separates from the wall of uterus, then
the uterus cannot contract properly so the blood vessels inside the uterus will continue to bleed
and the patient may result in being hypovolaemic shock.

If the third stage is manage and the delivery of the placenta takes longer than 30 minutes after the
birth of the baby, then the risk of having heavy bleeding increases. (Maganna et al 2005). Heavy
bleeding in the first 24 hours after birth is known as Primary Postpartum Hemorrhage (PPH)
which may also result in patient being hypovolaemic shock and than anemia after all.

If small fragments of placenta or membrane are retained and are not detected immediately, then
this may cause heavy bleeding and there may be infection later on. This is known as Secondary
PPH and happens in just less than one per cent of births.

The two other potential complications are uterine inversion and puerperal sepsis.

Reference:
1. Molar, G. 2005, Manual of Standard Managements in Obstetrics and Gyanecology for
Doctors, H.E.O.s and Nurses in Papua New Guinea, 5th edn, Chief Obstetrician
Gyanecologist for the Ministry of Health, PNG.
2. http://www.babycentre.co.uk/pregnancy/labourandbirth/labourcomplications/retainedplac
enta/ on 12/03/2011.
3. http://www.fpnotebook.com/ob/Ld/RtndPlcnt.htm on 13/03/2011.